Hostname: page-component-74656f9884-j7cmm Total loading time: 0 Render date: 2026-11-09T04:27:57.208Z Has data issue: false hasContentIssue false
  • English
  • Français

COVID-19 Resurgence: Lessons Learned to Inform the South African Response

Published online by Cambridge University Press:  19 April 2021

Mathias Dzobo ,
Mbuzeleni Hlongwa ,
Knowledge Denhere ,
Vincent Kampira ,
Mathias Mugoni ,
Godfrey Musuka  and
Tafadzwa Dzinamarira Open the ORCID record for Tafadzwa Dzinamarira [Opens in a new window]
Mathias Dzobo
Affiliation:
University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
Mbuzeleni Hlongwa
Affiliation:
University of KwaZulu-Natal College of Health Sciences, Durban, South Africa
Knowledge Denhere
Affiliation:
University of the Western Cape, Bellville, South Africa
Vincent Kampira
Affiliation:
ICAP, Columbia University, Harare, Zimbabwe
Mathias Mugoni
Affiliation:
Optimum Health Medical Laboratories, Gaborone, Botswana
Godfrey Musuka
Affiliation:
ICAP, Columbia University, Harare, Zimbabwe
Tafadzwa Dzinamarira*
Affiliation:
University of KwaZulu-Natal College of Health Sciences, Durban, South Africa
*
Corresponding Author: Tafadzwa Dzinamarira, Email: anthonydzina@gmail.com.
Rights & Permissions [Opens in a new window]

Abstract

The risk of recurring coronavirus disease (COVID-19) resurgences that threaten Africa’s health care systems, newly opened communities, schools, and businesses looms as communities abandon precautionary measures, such as mask-wearing, physical distancing, and regular handwashing. In this piece, we unpack the handling of both the first wave and subsequent resurgence in the context of 3 countries that are experiencing such a resurgence at the time of writing (December 2020): Israel, France, and the United Kingdom. While it is difficult to extrapolate on what to expect in South Africa, based on experience in these 3 countries, South Africa’s preparedness for a COVID-19 resurgence should place emphasis on the role of expanded testing and isolation capacity, strengthening enforcement of adherence to non-pharmaceutical interventions, and protection of high-risk populations.

Keywords

COVID-19preparednessresponseresurgenceSouth Africa

Information

Type
Commentary
Information
Disaster Medicine and Public Health Preparedness , Volume 16 , Issue 6 , December 2022 , pp. 2269 - 2274
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© Society for Disaster Medicine and Public Health, Inc. 2021

Introduction

In December 2019, a novel coronavirus was identified after a cluster of pneumonia cases of unknown cause were investigated in Wuhan, China. The causative agent was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is the cause of the coronavirus disease (COVID-19). Reference Guan, Ni and Hu1 Globally, the virus has infected 126.4 million people and caused more than 2.773 million deaths as of March 25, 2021. In Africa, the COVID-19 pandemic has spread to all countries under the World Health Organization (WHO) Africa Region. 2 South Africa, which constitutes 4.5% of Africa’s population, has reported over 35% (1 541 560) COVID-19 confirmed cases in the region and 47% (52 525) of the deaths in Africa as of March 25, 2021. 2 The high number of confirmed COVID-19 cases for South Africa has largely been due to the widespread testing conducted in the country compared with other African countries. As of March 25, 2021, South Africa has conducted the highest number of tests (over 9.7 million) and sixth highest number of tests per million population (162 444) in Africa. 3

The recent months have seen a resurgence of the virus in countries where virus transmission had dwindled to low rates as the first wave of the outbreak had waned. The risk of a resurgence that threatens Africa’s health care systems, newly opened communities, schools, and businesses looms as people abandon precautionary measures, such as mask-wearing, physical distancing, and regular handwashing. In this piece, we unpack the handling of both the first wave and subsequent resurgence in the context of 3 countries that are experiencing such a resurgence at the time of initial writing (December 2020): Israel, France, and the United Kingdom. We discuss measures that South Africa can take to mitigate the impact of a potential COVID-19 resurgence, learning from experiences in the first wave of infections.

Table 1.

COVID-19 first wave interventions for Israel, France, United Kingdom, and South Africa

Table 2.

COVID-19 second wave interventions in Israel, France, United Kingdom, and South Africa

First Wave Containment, Mitigation, and Easing of Lockdown Regulations

Israel

In Israel, the first infection of COVID-19 was confirmed on February 21, 2020, since the country had reported 35 085 cases and 295 deaths per million population as of November 13, 2020. 4 Israel’s Ministry of Health (MoH) implemented a raft of containment measures coupled with extensive testing during the early phase of the epidemic. The weekly number of cases pattern for Israel is presented in Figure 1. The containment measures included a 14-day home isolation for people arriving from any country outside Israel and people who had been in contact with a confirmed case of COVID-19. Symptomatic people were instructed to stay home for 2 days after symptom resolution. 5 On March 11, 2020, gatherings were limited to a maximum of 100 people; this was further restricted to 10 people by March 15, 2020. On March 19, 2020, a national state of emergency was declared in the country, and the first fatality due to COVID-19 was reported on March 20. Reference Rossman, Keshet and Shilo6 Restrictions on the movement of people were introduced with only essential workers and businesses (“essential services”) allowed to move freely. On April 8, 2020, an 1800 to 0700 hours curfew was imposed to prevent people from partaking in joint religious Passover dinners, as per tradition. Reference Keshet, Gavrieli and Rossman7 More details are presented in Table 1.

Figure 1.

Weekly number of new cases pattern in France, Israel, South Africa, and the United Kingdom.

On May 4, 2020, the Israeli Government approved a series of amendments to the lockdown regulations that allowed the economy to return to activity. The regulations included a selective return of the education system, retail sector, transportation, and domestic tourism. The government announced a gradual and controlled lockdown relief performed in 4 stages of decreasing strictness that could eventually allow gathering with no limitations. However, at this stage, the government defined one of the following criteria as a cause to return to lockdown: a report of 100 new daily cases of infection (excluding outbreak centers), a viral replication rate of less than 10 days, and 250 patients in a critical condition. 8

France

France introduced COVID-19 surveillance on January 10, 2020, 3 days after the identification of the SARS-CoV-2 in China. The first 3 imported cases of COVID-19 in France, the first ones in Europe, were reported 14 days later, on January 24, 2020. Reference Stoecklin, Rolland and Silue9 The weekly number of cases pattern for France is presented in Figure 1. As the number of cases rose, the French Government ordered the closure of schools and universities, pubs, restaurants, and cinemas on March 12, 2020. On March 16, 2020, the French President announced the beginning of a lockdown period from March 17, 2020, at noon. Reference Roux, Massonnaud and Crépey10 The lockdown period that was earlier planned for 15 days was extended further to May 11, 2020, due to a sharp increase in cases and deaths that took place in early April 2020. The president announced that there would be a gradual lifting of the lockdown after May 11, 2020, with schools and some workplaces reopening but social gatherings and leisure activities would remain banned until at least mid-July 2020. The second phase of the easing of lockdown restrictions was announced on May 28; this saw the previously imposed 100-km radius travel ban being removed and bars/pubs, schools, and restaurants reopening. 11 On July 10, 2020, the State of Health Emergency in France ended, essentially ending the national lockdown. However, there were still restrictions with emphasis on social distancing and the practice of regular personal hygiene. More details are presented in Table 1.

United Kingdom (UK)

As cases of COVID-19 rose sharply in Wuhan, China, Public Health England (PHE) announced that it would be moving the risk level to the British public from very low to low on January 22. All passengers aboard flights from Wuhan were screened on arrival at airports as part of the country’s containment measures. 12 The UK reported its first case of COVID-19 on January 31, 2020, and the country recorded the first death of a person in the UK on March 5, 2020. 4 The weekly number of cases pattern for the UK is presented in Figure 1. On March 3, 2020, the UK Government launched a 4-pronged action plan with emphasis on keywords contain, delay, research, and mitigate. The action plan provided information on the government’s plans to contain the spread of the virus and the action if the virus spreads in the population. 13 On March 12, 2020, the government shifted from containment to the delay phase, and the government urged people displaying COVID-19 symptoms to self-isolate at home for at least 7 days, no matter how mild their symptoms. Reference Mahase14 A modeling study conducted by the Imperial College London advised the government to use non-pharmaceutical interventions to reduce the impact of COVID-19-related deaths. These measures included social distancing and isolation of entire households when a family member tested positive, as well as people over age 70 years. Reference Ferguson, Laydon and Nedjati Gilani15 Facing a serious threat of an overwhelmed health system, the UK announced a total lockdown on March 23, 2020, to curb the spread of COVID-19. The government implemented a range of measures, including travel restrictions, social distancing measures, closures of entertainment industry, hospitality, non-essential shops and indoor premises, and increased testing. On May 10, 2020, the government set out a roadmap to ease the lockdown. In the first step, May 13–31, 2020, people were requested to work from home, while those working in the manufacturing and construction sectors were encouraged to go back to work minimizing the use of public transportation. In step 2, from June 1, 2020, some schools and outdoor markets were allowed to reopen, while all other non-essential retail industries reopened on June 15, 2020. In step 3, starting on July 4, 2020, the hospitality and personal care industries, as well as public places, reopened while enforcing social distancing. 16

South African Context: Containment, Mitigation, and Easing of Lockdown Regulations

South Africa’s National Institute of Communicable Diseases (NICD) reported its first confirmed COVID-19 case on March 5, 2020. Reference Staunton, Swanepoel and Labuschagine17 The weekly number of cases pattern for South Africa is presented in Figure 1. The South African Government declared a national state of disaster on March 16, 2020. A total lockdown came into effect at midnight on March 26, 2020. 16 Under this declaration, South Africans were urged to observe simple hygiene rules of regular handwashing, social distancing, restricted public gatherings, and meetings to less than 100 people. Restaurants, shops, hubs, churches, and mosques were closed down and there was a ban on the sale of alcohol and tobacco cigarettes. These measures were to curb person-to-person transmission and the spread of the virus. Reference Goon and Okafor18 The South African lockdown was considered one of the most stringent in the continent and possibly globally.

On May 1, 2020, a phased lifting of the lockdown began; the country was moved into level 4, allowing selected sectors to resume operations. On May 13, 2020, a further relaxation of the lockdown was announced, effective June 1, 2020, effectively lowering the restrictions to level 3. Most economic activities reopened under strict health and social distancing practices, except for high-risk ones, for example, entertainment, sporting activities, and conferences. The sale of tobacco remained banned, but the regulated sale of alcohol was allowed. On July 12, 2020, in response to a growing number of COVID-19 cases, a curfew and an alcohol ban were reintroduced and the wearing of face masks in public was made mandatory. The national state of disaster was extended to October 31, 2020. On September 21, 2020, the government scaled down from level 2 to level 1 and eased most of the lockdown restrictions, including international travel to other countries in response to the low number of positive COVID-19 cases. 19

COVID-19 Second Wave in Israel, France, and the United Kingdom

Israel, France, and the UK were among the first few countries in the world to respond to a resurgence in COVID-19 cases, interchangeably commonly referred to as a second wave of COVID-19. Table 2 presents COVID-19 second wave interventions in Israel, France, United Kingdom and South Africa.

Israel

Israel has experienced a resurgence of COVID-19 cases since May, when it eased the nationwide lockdown imposed at the start of the pandemic. Israel’s coronavirus cabinet task force approved the “traffic light” plan to tackle the rising COVID-19 infections on August 30, 2020. According to the color-coded system, which commenced on September 6, 2020, restrictions on cities were decided by morbidity rates, green (no restrictions), yellow (minor restrictions), orange (significant restrictions), and red (significant restrictions, including lockdowns). 20 On September 6, 2020, a 1700 to 0500 hours curfew was imposed on 40 “red zone” communities across the country. On September 10, 2020, Israel became the country with the highest rate of COVID-19 infections per capita. 21 The virus had infected almost 140 000 of its 9 million population, causing growing criticism of how the prime minister was handling the new wave of infections. 21 On September 13, 2020, Israel became the first country in the world to impose a second lockdown. The new lockdown measures restricted people to within 500 meters of their homes, except for work and essential activities, such as buying food and pharmacy goods, as well as attending synagogue. On September 23, 2020, a number of cases continued to rise (see Figure 1), Israel imposed a full lockdown over the entire country, with more severe and stricter restrictions than the first lockdown as COVID-19 cases surged. The country’s MoH warned that hospitals were quickly approaching full capacity.

France

France is facing a second wave of COVID-19, which is more serious than the first. During the country’s first wave, France’s daily new case numbers reached a peak of just over 7500 on March 31, 2020. On October 15, 2020, France became the first country in Europe to record more than 30 000 cases in a day, with 30 621 cases reported. 4 An 1800 to 0900 hours curfew was imposed in 9 of the country’s largest cities, including Paris. These new regulations came into effect on October 17, 2020. The cities have a combined population of about 20 million people. On October 29, 2020, a second national lockdown was announced. 22

United Kingdom

The UK is experiencing some of the highest new daily cases of COVID-19 in the world. The UK reported an average of 14 391 new daily cases in the week of October 12, 2020. 4 The European Centers for Disease Control and Prevention (ECDC) also reported a growing number of hospitalizations in the UK. In response, the British Government introduced a new 3-tier (medium, high, and very high tiers) system of local COVID-19 alert levels in their varying stages of severity. 23 The medium tier is a continuation of the measures that are currently in place, such as the rule of 6 and the 2200 hours curfew. Most parts of England are under the medium tier. The high tier will see restrictions that are more stringent on household interactions. The rule of 6 will be maintained at outdoor gatherings. The very high tier restrictions will be applied to areas where infection rates are causing national concern. Social mixing, leisure, and entertainment in these areas will be banned in consultation between local and central governments, but retail, schools, and universities will remain open. There are growing fears that the newly announced 3-tier system may not bring down the rate of infections without the citizens buying into the measures. Several government advisors believe the idea of containing the virus region-by-region is bad for national unity, and instead, they are advocating for a circuit-breaker type of lockdown. A circuit-breaker lockdown would therefore see British citizens stop all contact with people outside their households by shutting non-essential businesses and stopping social interactions. The idea is to interrupt the rate of virus transmissions and allow time for a longer-term plan to be implemented before cases overwhelm the health systems and increase health care worker burnout. 24

Lessons Learned to Inform the South African Response/Mitigate the Impact of a COVID-19 Resurgence

South Africa is anticipating another COVID-19 resurgence in the next few months. 25 In South Africa, the marked increase in new COVID-19 infections (December 2020–February 2021) was associated with the decline in adherence to lockdown restrictions and other measures, such as social distancing, regular sanitizing or handwashing, and mask wearing. In response to COVID-19 resurgences, some countries, such as Israel 20 and France, Reference Daventry26 introduced new rounds of curfews and lockdown restrictions to curb the spread of the virus. These public health measures are important to control the transmission of COVID-19. While this is the case, some of the strategies implemented by these countries may not necessarily be as effective in South Africa.

South Africa may attempt to implement curfews and lockdown restrictions to reduce COVID-19 transmission. However, while hard lockdowns managed to slow the rapid spread of COVID-19 at the initial stages, these did not manage to stop the transmission of the virus at the anticipated rates. The reproductive rate of the South African epidemic under various stages of lockdown paradoxically showed a decline as the country went to lower levels of restrictions. 27 This now suggests less chance of being able to achieve sustained suppression of virus circulation in South Africa through a lockdown, than was the case when circulation initially started. 27 Second, unlike in UK and France, the timing of the initial lockdown and the likely goals to be achieved differ between the countries. The South African lockdown, unlike in the UK, was not because of impending collapse of health services. It is also worth noting that due to lockdown, many people lost income, while poverty widened Reference Van Der Berg28 and concerns on a rapid rise of mental health issues arose. Reference Magamela, Dzinamarira and Hlongwa29 Further hard lockdowns will prove to have dire consequences for the economy.

Following lessons from South Korea, South Africa could mitigate the anticipated COVID-19 resurgence by implementation of robust testing and isolation capacity at community levels. These should be coupled with enforcing strict restrictions on non-pharmaceutical interventions that include mask-wearing, handwashing or sanitizing, social distancing, and reduction of social gatherings. Reinforcement of infrastructure at both public and private health care institutions, as well as protecting high-risk populations, such as elderly and those with comorbidities, remains as important strategies to reduce impact of a COVID-19 resurgence. South Africa recently rolled out a COVID-19 vaccination program. Reference Dzinamarira, Nachipo, Phiri and Musuka30 Efforts to scale up coverage to and ensure high-risk groups are vaccinated before the anticipated surge will further reduce the impact of the anticipated resurgence.

Conclusion

While it is difficult to extrapolate on what to expect in South Africa, based on experience in Israel, France, or the UK, emphasis should be placed on the role of expanded testing and isolation capacity, strengthening enforcement of adherence to non-pharmaceutical interventions, and protection of high-risk populations.

Conflict(s) of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this paper.

References

Guan, W-J, Ni, Z-Y, Hu, Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708-1720.CrossRefGoogle ScholarPubMed
World Health Organization. COVID-19 in the WHO African region. 2021. https://who.maps.arcgis.com/apps/opsdashboard/index.html#/0c9b3a8b68d0437a8cf28581e9c063a9. Accessed March 7, 2021.Google Scholar
World Health Organization. Novel coronavirus (COVID-19). 2020. https://www.who.int./emergencies/diseases/novel-coronavirus-2019. Accessed March 6, 2021.Google Scholar
ECDC. European Centre for Disease Prevention and Control: COVID-19 situation update. 2020. https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-cases. Accessed October 26, 2020.Google Scholar
MoH. State of Israel Ministry of Health: November coronavirus. 2020. https://www.health.gov.il/English/Topics/Diseases/corona/Pages/default.aspx. Accessed October 26, 2020.Google Scholar
Rossman, H, Keshet, A, Shilo, S, et al. A framework for identifying regional outbreak and spread of COVID-19 from one-minute population-wide surveys. Nat Med. 2020;26(5):634-638.CrossRefGoogle ScholarPubMed
Keshet, A, Gavrieli, A, Rossman, H, et al. The effect of a national lockdown in response to COVID-19 pandemic on the prevalence of clinical symptoms in the population. medRxiv. 2020;epub, https://doi.org/10.1101/2020.04.27.20076000.CrossRefGoogle Scholar
KPMG. Government and institution measures in response to COVID-19: 22 July, 2020. 2020. https://home.kpmg/xx/en/home/insights/2020/04/israel-government-and-institution-measures-in-response-to-covid.html. Accessed October 26, 2020.Google Scholar
Stoecklin, SB, Rolland, P, Silue, Y, et al. First cases of coronavirus disease 2019 (COVID-19) in France: surveillance, investigations and control measures, January 2020. Eurosurveillance. 2020;25(6):2000094.Google Scholar
Roux, J, Massonnaud, C, Crépey, P. COVID-19: one-month impact of the French lockdown on the epidemic burden. medRxiv. 2020;epub, https://doi.org/10.1101/2020.04.22.20075705.Google Scholar
France 24. France begins ‘Phase II’ of easing lockdown measures as coronavirus abates. 2020. https://www.france24.com/en/20200602-france-lifts-more-covid-19-restrictions-what-you-need-to-know-for-phase-ii. Accessed October 26, 2020.Google Scholar
Independent. Coronavirus: a timeline of how Britain went from ‘low risk’ to an unprecedented national shutdown. 2020. Accessed October 26, 2020.  https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-9-impact-of-npis-on-covid-19/ Google Scholar
GOV.UK. Coronavirus action plan launched. 2020. https://www.gov.uk/government/news/coronavirus-action-plan-launched. Accessed October 26, 2020.Google Scholar
Mahase, E. COVID-19: UK holds off closing schools and restricts testing to people in hospital. BMJ. 2020;368:m1060.CrossRefGoogle ScholarPubMed
Ferguson, N, Laydon, D, Nedjati Gilani, G, et al. Report 9: impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. 2020. https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-9-impact-of-npis-on-covid-19/. Accessed November 30, 2020.Google Scholar
IMF. International monetary fund: policy responses to COVID-19. 2020. https://www.imf.org/en/Topics/imf-and-covid19/Policy-Responses-to-COVID-19#U. Accessed October 26, 2020.Google Scholar
Staunton, C, Swanepoel, C, Labuschagine, M. Between a rock and a hard place: COVID-19 and South Africa’s response. J Law Biosci. 2020;7(1), https://doi.org/10.1093/jlb/lsaa052.Google Scholar
Goon, TD, Okafor, UB. Curbing the COVID-19 pandemic in South Africa: taking firmer, aggressive measures and discarding fallacy theories. Open Public Health J. 2020;13(1).Google Scholar
WorldAware. COVID-19 alert: South Africa to move to level 1 restrictions from Sept. 21 2020. https://www.worldaware.com/covid-19-alert-south-africa-move-level-1-restrictions-sept-21. Accessed October 27, 2020.Google Scholar
i24News. Israel: COVID-19 death toll rises to 919; gov’t approves ‘Traffic Light’ plan. 2020. https://www.i24news.tv/en/news/coronavirus/1598812319-israel-covid-19-death-toll-rises-to-919-gov-t-approves-traffic-light-plan. Accessed October 27, 2020.Google Scholar
Middle East Eye. Analysis: Netanyahu’s zigzags leave Israel number one in COVID-19 infection rate. 2020. https://www.middleeasteye.net/news/israel-netanyahu-coronavirus-number-one-covid-infection-rate. Accessed October 27, 2020.Google Scholar
BBC. Coronavirus: Macron declares second national lockdown in France. 2020. https://www.bbc.com/news/world-europe-54716993. Accessed November 14, 2020.Google Scholar
The Guardian. Tier 1, 2 or 3? England’s COVID lockdown rules explained. https://www.theguardian.com/world/2020/oct/15/tier-1-2-or-3-englands-three-stage-covid-lockdown-rules-explained. Accessed October 27, 2020.Google Scholar
The Telegraph. Will England go into a ‘circuit breaker’ lockdown? https://www.telegraph.co.uk/news/2020/10/22/what-circuit-breaker-lockdown-covid-uk-how-work/. Accessed October 27, 2020.Google Scholar
Eye Witness News. SA considering inoculations with 2 different COVID-19 vaccines – Madhi. https://ewn.co.za/2021/02/08/sa-considering-inoculating-individuals-with-2-different-covid-19-vaccines-madhi. Accessed March 26, 2021.Google Scholar
Daventry, M. Curfews and restrictions imposed across Europe as COVID-19 cases soar. Euronews. 2020. https://www.euronews.com/2020/10/23/curfews-and-restrictions-imposed-across-europe-as-covid-19-cases-soar. Accessed October 27, 2020.Google Scholar
The Scientists Collective – COVID-19 anticipating a ‘second wave’ – and when and how South Africa should try to prevent or mitigate it. Daily Maverick. 2020. https://www.dailymaverick.co.za/article/2020-10-22-anticipating-a-second-wave-and-when-and-how-south-africa-should-try-to-prevent-or-mitigate-it/. Accessed November 11, 2020.Google Scholar
Van Der Berg, S. Poverty rises, inequality shifts as COVID-19 impact continues unabated. May 9, 2020. http://resep.sun.ac.za/poverty-rises-inequality-shifts-as-covid-19-impact-continues-unabated/. Accessed October 27, 2020.Google Scholar
Magamela, MR, Dzinamarira, T, Hlongwa, M. COVID-19 consequences on mental health: an African perspective. S Afr J Psychiatr. 2021;27:2.Google ScholarPubMed
Dzinamarira, T, Nachipo, B, Phiri, B, Musuka, G. COVID-19 vaccine roll-out in South Africa and Zimbabwe: urgent need to address community preparedness, fears and hesitancy. Vaccines. 2021;9(3):250.Google ScholarPubMed
Figure 0

Table 1. COVID-19 first wave interventions for Israel, France, United Kingdom, and South Africa

Figure 1

Table 2. COVID-19 second wave interventions in Israel, France, United Kingdom, and South Africa

Figure 2

Figure 1. Weekly number of new cases pattern in France, Israel, South Africa, and the United Kingdom.